MAL 530

Medical Assistance Letter (MAL) 530

June 7, 2007

To:                Comprehensive Clinics, Dental Clinics, Diagnostic Clinics, Family Planning Clinics, Mental Health/ADAS Clinics, Optometry Clinics, Public Health Department Clinics, Rehabilitation Clinics

Trading Partners and Tape Intermediaries

Directors, County Departments of Job and Family Services

Medical Assistance Coordinators

From:            Helen E. Jones-Kelley, Director

Re:                Information Providers Must Know about the National Provider Identifier (NPI) in Order to Get Paid

NPI………………GET IT..........................SHARE IT........................USE IT

The purpose of this Medical Assistance Letter (MAL) is to inform Ambulatory Health Care Clinic providers who are enrolled in the Ohio Medicaid program and do business with ODJFS that they are required to obtain a National Provider Identifier (NPI) by May 23, 2007. An NPI for the clinics is a unique, ten-digit identifier that providers receive from the National Plan and Provider Enumeration System (NPPES). Upon receipt of their NPI and until January 1, 2008, clinic providers that conduct business with Medicaid in an electronic format (i.e., submit EDI claims, receive electronic remittance advices and/or communicate electronically with trading partners and payers) must submit both their NPI number and their current Medicaid provider number (now referred to as the Medicaid legacy number or Ohio Medicaid legacy number) in accordance with the Ohio Medicaid EDI companion guide and/or the instructions contained in this MAL.* This is to create an association between these two numbers.

Clinics MUST enumerate through NPPES, disclose their NPI to ODJFS and bill ODJFS using both their NPI and Medicaid legacy identifiers. This MAL provides direction to clinic providers on enumerating through NPPES, disclosing your NPI to ODJFS, and billing ODJFS using your NPI.*

Clinic provider claims received by ODJFS before January 1, 2008 that contain a valid Ohio Medicaid legacy number, or both a valid NPI and valid Ohio Medicaid legacy number in the required provider fields, will continue to be accepted and processed. Claims submitted without an Ohio Medicaid legacy number (i.e., submitted only with an NPI number) prior to January 1, 2008 will be rejected or denied.*

Clinic provider claims submitted to ODJFS on or after January 1, 2008 will be denied if the clinic provider's NPI number is not in the required field(s) on the claim. Clinic provider claims submitted on or after May 23, 2008 will not require the Ohio Medicaid legacy number if ODJFS has a record of your NPI number and has linked the NPI to your Ohio Medicaid legacy number.

*         See special instructions for paper and tape claims (below in this MAL).

I.         How do I get an NPI?

Clinic providers can receive an NPI number by submitting an NPI application to NPPES. To obtain an NPI, clinic providers should contact NPPES directly at http://nppes.cms.hhs.gov or by phone at 1-800-465-3203 (or 1-800-692-2326 (TTY)). Clinic providers can apply for an NPI electronically or by paper.

When you apply for your NPI, ODJFS encourages you to submit the following information with your NPI application:

·          Ohio Medicare legacy (PIN) number,

·          Ohio Medicaid legacy number,

·          taxonomy number, and

·          employer identification number (EIN).

It is also important that you make it clear that you are applying for an NPI for a non-individual, Ambulatory Health Care Facility clinic provider. A listing of taxonomy codes for clinic providers can be found at http://www.wpc-edi.com/codes/taxonomy.

II.        How must my NPI relate to my Medicaid legacy number?

If your clinic received this MAL, you submitted a claim or claims as a clinic provider at least once during the last twelve months. When clinic providers enroll to do business with ODJFS, they are issued a clinic provider Medicaid legacy number. When clinic providers subsequently submit claims for payment, ODJFS expects the billing provider, the pay to provider and the rendering provider to be the same (the clinic provider).

Services rendered by other practitioners employed by or under contract with the clinic provider should be billed under the clinic provider's NPI and the clinic provider's Medicaid legacy number (when both numbers are required). This directive applies as soon as you receive your NPI number and remains in effect after January 1, 2008.

Clinic providers must submit only the non-individual NPI assigned to them with the Ohio Medicaid legacy number that was issued to them as an individual clinic provider. Only one NPI number can be associated with your individual Ohio Medicaid legacy number. A clinic provider's NPI should never be submitted to ODJFS with a Medicaid legacy number that belongs to any other provider.

III.       How do I bill ODJFS using the NPI?

The billing instructions contained in this MAL are for clinic providers. Instructions for submitting the NPI are also contained in the ODJFS EDI 837 Professional Companion Guide, which is available at: http://jfs.ohio.gov/OHP/providers/npi.stm (see the box titled "Trading Partner").

Billing NPI on EDI 837 Professional Claims

The information in this section is technical but is intended to assist you in making the appropriate arrangements with your trading partner to receive your NPI number and to submit your NPI number on your EDI claims and other transactions. A copy of this MAL will also be issued to each EDI trading partner doing business with ODJFS.

The clinic's NPI number must be entered in the primary identifier field on ASCII X12 837 health care transactions. The clinic provider's NPI must be sent with the XX qualifier in the NM108 and the NPI in the NM109 of the 2010AB (for the pay to provider information) loop and/or 2010AA (for the billing provider information) loop. Prior to January 1, 2008, the clinic provider's Medicaid legacy provider number must also be sent with the 1D qualifier in the secondary identification qualifier location REF01 and the Medicaid legacy number in the secondary identification location REF02 of loops 2010AB and/or 2010AA. The EDI standard does not require the rendering provider loop(s) to be completed if the rendering provider is the same as the pay to provider. For clinics billing Medicaid, the pay to provider and the rendering provider are always the same provider. Do not send NPI information in the NM108 and NM109 nor the Medicaid legacy information in the REF01 and REF02 of the rendering provider loops (neither loop 2310B nor 2420B).

Note: Dental school clinics use the 837D (dental) and all other clinics use the 837P (professional).

Billing on Paper Claims or by Tape

* Special Instructions for Paper and Tape formats

ODJFS is no longer accepting tape formats.

Beginning May 23, 2007, ODJFS will start to accept the Center for Medicare and Medicaid Services (CMS) 1500 (08/05) paper form (also referred to as the new CMS 1500). Providers may continue to send the CMS 1500 (12-90) paper form (also referred to as the old CMS 1500).

Clinic providers using the old CMS 1500 (required until announced) must submit a Medicaid legacy number wherever a provider number (identifier) is required on the claim. Submitting an NPI number on the old CMS 1500 will cause the claim to reject or may cause the claim to pay inappropriately.

Providers submitting the new CMS 1500 must submit both the NPI and the Medicaid legacy number (identifier) in accordance with the ODJFS New CMS 1500 (08/05) Billing Instructions.

Note: Dental school clinics should continue to use the American dental Association (ADA) 2000 paper form. ODJFS will continue to only accept the old ADA 2000 until a date for the adoption of the new ADA 2006/7 is established and announced by ODJFS.

IV.      Why am I required to get an NPI?

The Code of Federal Regulations, CFR 45, Subpart D, Section 162.410 (a) (1) through (a) (6), requires clinic providers to obtain an NPI, to use it on all standard transactions where a provider identifier is required, and to disclose their NPI, when requested, to any entity that needs the NPI to identify that provider in a standard transaction, including standard transactions sent to any health plan (i.e., Medicaid, Medicare or any other health plan). ODJFS must also comply with the federal regulations.

V.       Am I required to share my NPI number with ODJFS?

Yes, the clinic provider must disclose to ODJFS the NPI number that has been assigned to the provider. If you do not disclose your NPI to ODJFS, ODJFS will not be able to recognize you as a valid Medicaid provider. This could cause your claims to deny.

Instructions on how to disclose your NPI information to ODJFS can be obtained under "SHARE IT!" from the following site: http://jfs.ohio.gov/OHP/providers/npi.stm.

VI.      Am I required to share my NPI with other entities?

Yes, as stated in Section V above, you are required to disclose your NPI, when requested, to any entity that needs the NPI to identify the clinic provider in a standard transaction. This includes disclosing your NPI to Medicaid, Medicare, other health plans and other health care providers.

VII.     I heard that the date for NPI implementation has been extended. Is that true?

No, the law still requires providers of health care and health (except small) plans to be in compliance with the NPI regulations on May 23, 2007. However, for a 12 month period, CMS will not impose penalties on covered health plans that deploy contingency plans (in order to ensure the smooth flow of payments) if they have made reasonable efforts to become compliant and to facilitate the compliance of their providers and trading partners.

VIII.    Has ODJFS deployed a contingency plan?

Yes, ODJFS has deployed a contingency plan as detailed in this MAL.

IX.      What is meant by a dual identifier period?

A dual identifier period is the time period in which a health plan can require both the NPI and the plan' legacy (or proprietary) number on claim formats and may deny claims that are missing the plan's legacy number.

The purpose of the dual identifier period is to give health plans and providers the opportunity to assure the provider will get paid without interruption once NPI is fully implemented. It is in the provider's best interest to have a significant volume of claims that have both identifiers and have been submitted early enough for ODJFS to assist the provider in correcting any NPI-related billing problems, prior to the end of the ODJFS dual identifier period.

As a part of ODJFS' NPI contingency plan, ODJFS has extended its dual identifier period to December 31, 2007. During this extended period ODJFS requires both the Medicaid legacy identifier and the national provider identifier (NPI). Failure to continue to send the Medicaid legacy identifier during the ODJFS dual identifier period will result in non-payment or the rejection of claims.

Providers and trading partners will be notified in the event ODJFS believes the ODJFS dual identifier period can end sooner than December 31, 2007, or needs to be extended to the CMS approved date of May 23, 2008.

ODJFS appreciates the attention of the clinic providers in this matter, and as a result of their cooperation anticipates a successful transition to NPI enumeration.

Questions pertaining to this MAL should be addressed to:

Bureau of Plan Operations

The provider Services Section

P.O. Box 1461

Columbus, Ohio 43216-1461

Toll free telephone number 1-800-686-1516

You can also obtain information about NPI as it pertains to the Ohio Medicaid program at http://jfs.ohio.gov/OHP/providers/npi.stm

NPI………………GET IT..........................SHARE IT........................USE IT